APPLICATION FOR EMPLOYMENT - FACULTY
Name:
Soc. Sec. No. *
Last
First
Middle
*The disclosure of this number is voluntary. If hired, it is mandatory that you provide this number for withholding taxes, medical insurance, and
identification purposes, pursuant to 26 USC Sections 6051 and 3402 (f) (5).
Address:
Phone:
Number and Street
City
State
Zip
POSITION DESIRED
Department:
Minimum Salary Acceptable $
on the basis of :
One semester
Two semesters
Academic Rank applied for:
If hired, on what date will you be available for work?
PROFESSIONAL QUALIFICATIONS AND INTERESTS - please attach resume
COLLEGE AND UNIVERSITY EDUCATION
Institution Name & Address
Major Subject
Name and Address of
MAJOR Professor or
Principal FACULTY Advisor
Degree Received
& Date
CHRONOLOGY OF EMPLOYMENT
Employed
From
MO
To
YR
MO
YR
Name and Address of Employer
or Department Head
May we contact your current/former employer?
Yes
Position and Duties
No
Michigan Technological University is an Equal Opportunity Educational Institution/Equal Opportunity Employer,
which includes providing equal opportunity for protected veterans and individuals with disabilities.
Rev. 10/16/14
REFERENCES
Name
Address
Occupation
Years
Acquainted
If hired can you provide the documents required to p r o v e that y o u a r e legally able to work in the U.S. in the job for w h i c h you are
applying?
Yes
No
The University will not pay any attorney fees or other costs to help obtain or extend a visa or change visa status. If you have any
questions on this subject, the University urges you to consult an attorney. Should your employment eligibility expire, it will be
necessary to remove you from payroll immediately.
Do you have relatives, excluding a spouse, working here?
Yes
No
Yes
No
Yes
No
If yes, state relationship, position at MTU, and department
Have you ever been suspended or discharged from any position?
If yes, give particulars
Are you presently under arrest for a felony or have you been convicted of a crime?
If yes, give details
A personal security investigation may be required from some appointees having access to classified research; would you agree to such
an investigation if needed?
Has security clearance ever been refused or withdrawn?
Yes
No
Yes
No
What security clearances have you been given?
Regarding federal and state laws to protect individuals with disabilities, will you need any accommodation in order to perform the
essential functions of the position(s) for which you are applying?
Yes
No
Please describe the accommodation you believe is needed, if any
If accepted for employment, you will be required to enter into a patent, research, and proprietary rights agreement which is substance (1)
obligates you to report the University discoveries, inventions, or other proprietary information developed by you, (2) gives the University
the option to take over and finance such discoveries, inventions, or proprietary material, and (3) in the event the University exercises the
option, provides for the payment to you of the initial $1,000 of income, 15 percent of the income between $1,000 and $30,000, and 33.3
percent of income in excess of $30,000. Would you be willing to enter into such an agreement?
Yes
No
I hereby represent that each answer is truthful and constitutes a full and complete disclosure of my knowledge with respect to the
questions and I understand that my misrepresentation of facts shall constitute cause for dismissal regardless of when discovered by the
University.
In the event that I am employed by Michigan Technological University, I agree to comply with all its rules and regulations.
Date:
Signature:
The need for an accommodation does not necessarily bar employment. A determination will be made as to the effectiveness with which the accommodation will allow
you to perform the essential functions of the position and hardship it would impose on the employer.
Michigan Technological University is an Equal Opportunity Educational Institution/Equal Opportunity Employer,
which includes providing equal opportunity for protected veterans and individuals with disabilities.
Rev. 10/16/14